Yemen: Health Inequality Between the Genders

** This essay by Teresa Logue won the first place prize in the Yale Global Health Review 2014 Class Essay Contest**

Though it is the second largest country in the Arabian peninsula, Yemen has the second lowest Human Development Index (HDI) in the entire Asia region.[i] The population of Yemen experiences crushing poverty nationwide, and a [ii] low life expectancy at birth, (63 for males and 66 for females.[iii]Accordingly, Yemen’s total health expenditure of $40 per capita annually is among the lowest in the world.[iv]Spending just 1.8% of its GDP on health, Yemen’s health system remains grossly underfunded and underdeveloped.[v] As part of the 2011 Arab Spring, Yemeni citizens rose up in protest against their unresponsive government, calling for social sector reform.[vi] The new coalition government has grappled with, among other things, improving the delivery of health care services across the country, but reform has been progressing slowly.[vii] However, it is urgently needed, especially to correct for major inequities. Yemen’s overall loss in potential human development due to inequality was 32.3% in 2013.[viii] Gender-based disparities represent Yemen’s biggest health justice issue, and should be immediately addressed.

Key Health Inequities

Yemen has major inequities in health status, the most obvious of which occur across income (poor-rich) and geographic (rural-urban) lines. In terms of health outcomes, children in the poorest quintile are twice as likely to suffer life-threatening diarrhea and acute respiratory infections (ARIs) as those in the richest quintile.[ix]

In terms of health care utilization, children in the richest quintile are 6 times as likely to receive full immunization and 1.5 times as likely to receive medical treatment for ARIs as those in the poorest quintile.[x] About 74% of women in the highest income quintile give birth with a professional delivery attendant, compared to only 17% of women in the lowest quintile.[xi] Where available, health services are underutilized by the poor due to inability to pay user fees. Out-of-pocket (OOP) spending is rampant, and accounts for 75% of total health care expenditure.[xii] As a share of total consumption expenditure, households in the poorest quintile spend half of what those in the richest spend on health, suggesting that health expenses discourage the poor from seeking care.[xiii] While cash-transfer programs like the Social Welfare Fund exist to offset some of this burden, about half the transfers from public programs leak to the non-poor.[xiv] Furthermore, the rich often subvert Yemen’s health system and seek medical care elsewhere, such that 30% of total health expenditure in Yemen is spent abroad.[xv]

A second major inequity occurs between urban and rural populations. The majority (75%) of Yemenis live in rural areas.[xvi] In rural Yemen, direct state control is weak, which results in low coverage of health services, no emergency medicine, and childhood deaths from preventable diseases.[xvii] Only 25% of rural areas are covered under public sector services, compared to an 80% coverage rate in urban areas.[xviii] Just 26% of deliveries in rural areas are attended by skilled health personnel, as opposed to 62% of births in urban areas.[xix] Food insecurity is a “long-term chronic emergency” in Yemen, with malnutrition notably worse in the rural governorates.[xx] The prevalence of severe stunting in children between 2 and 5 years old is also higher in rural areas (33.2%) than urban ones (23.5%).[xxi] There is a 12-percentage point difference in measles immunization coverage between children in urban and rural areas.[xxii]

While income-based and geographic-based disparities are most apparent from indicators of child and maternal health in Yemen, gender-based inequities overlay both, representing Yemen’s biggest health justice problem. Yemen has a Gender Inequality Index (GII) value of 0.747, ranking last out of all 148 countries in UNDP’s 2012 index.[xxiii] Yemen’s high maternal mortality ratio of 200 betrays the low health status of women in Yemen.[xxiv] Because 42% of female deaths in the reproductive age range are linked to childbirth, maternal mortality is the most pressing women’s health issue.[xxv] A woman in Yemen has a 1 in 39 chance of dying in pregnancy or childbirth over her lifetime, and about 7 Yemeni women die each day from childbirth.[xxvi][xxvii] Only 36% of births are attended by skilled health personnel, due to lack of access to formal care.[xxviii] In all but one governorate in Yemen, half or more of all women report not having access to a formal health care provider.[xxix] Yemen holds one of the shortest median birth intervals in the world at 25.3 months, and just 54% of demand for family planning services is met.[xxx][xxxi] Significant barriers impede female access to health care: twice as many men as women can afford medical care, preventative care, regular visits, and medications.[xxxii] The majority (71%) of women must be accompanied by a male relative on visits to health care providers.[xxxiii] This constraint often applies in times of emergency and can further prevent a pregnant woman from receiving proper obstetric care.[xxxiv]

Rationale for Addressing Gender-Based Inequities

Gender-based inequities should be addressed immediately; and improvements in women’s health have trickle-down benefits for children and for society at large. Lack of access to maternal health care retards not only the health status of the mother, but that of the child too: and just 14% of women in Yemen have at least 4 antenatal care visits and only 12% of infants are exclusively breastfed for the first six months as per WHO recommendations, which implies childhood underweight.[xxxv] Beyond access to maternal care, women’s status in society is associated with health outcomes in children: empowering women to make decisions at home and in their communities enables them to provide better care and nutrition for their children.[xxxvi] It was estimated that if women had equal status relative to men in nearby South Asia, the under-three child underweight rate in the region would decrease by 13%.[xxxvii] Improving the social status of women will improve both mother and child health. Finally, the elimination of gender inequities and the reduction of maternal mortality are linked to increases in GDP per capita and economic growth.[xxxviii]

Addressing Gender-Based Inequities

Yemen should look to the Sri Lankan example of addressing maternal mortality by coupling interventions to extend health care to women with policy efforts to improve their autonomy and social standing. Sri Lanka has seen exceptional progress in achieving high women’s health outcomes, especially in the context of its low GDP per capita average annual growth rate (3.0%), which is comparable to Yemen’s (1.1%).[xxxix][xl] Over the past 50 years, Sri Lanka’s maternal mortality rate declined from 340 to 13, and its percentage of female deaths in the reproductive age range due to maternal causes dropped from 19% to 1.2%.[xli][xlii]

Interestingly, low female mortality in Sri Lanka today has been linked to transferring agency for health-related decision-making to women. To achieve this, Sri Lanka aggressively invested in mass education of girls, which was “the single most important reason why infant and child health has improved.”[xliii] Education has brought women autonomy, made them knowledgeable about health, increased demand for skilled attendance at birth and family planning services, and encouraged them to take a more active role in child care. Yemen has low rates of female literacy (30%) and secondary education amongst women (7.6%).[xliv][xlv]Accordingly, men tend to be the decision-makers for the family, and community health workers target their health message guidelines to them.[xlvi] Yemen should prioritize the education of girls to empower women to take on this role instead. Further, education is directly linked to access to health services in Yemen, with 71% of Yemeni women with secondary education reporting access to a health care provider.[xlvii]

Encouraging women’s political participation, as well as outlawing child marriage and female genital mutilation, are additional cost-effective policy avenues to improve the status of women in Yemen. Holding just 0.7% of seats in parliament, women have a paucity of political power.[xlviii] Child marriage is currently unregulated, and over half of girls are married before 18, with some married as young as 8.[xlix] Many become pregnant soon after, and Yemen’s adolescent fertility rate is very high, at 66.1.[l] Most child brides have insufficient information on family planning, and so little to no control over how far apart their pregnancies are spaced. Along with young age, this makes them more vulnerable to complications from pregnancy.[li] At a prevalence of 38.2%, female genital mutilation is a pervasive problem, especially because FGM exposes both women and their babies to significant risk during childbirth.[lii]

In addition to women’s empowerment, Sri Lanka’s program to reduce maternal mortality rested on extensive investment in health infrastructure; and Yemen should look to the Sri Lankan model for service provision. In the 1930s, Sri Lanka began building an extensive health service network to offer basic preventative and curative services for free to the entire population, including those in rural areas, which is still in place today.[liii] At its lowest level, the architecture is comprised of small health units staffed by a medical officer, who has access to a strong referral system and reliable emergency transport.[liv] In 1950, the government began developing and integrating a program of public health midwifery into the system.[lv] Sri Lanka’s public health midwives undergo 18 months of clinical training before being assigned to serve a community of 3,000 to 5,000 people in which they live. As frontline workers, they provide family planning services, visit pregnant women, register them for care, provide advice, and report to a network of supervisors with the area medical officer at the top. When necessary, they conduct home deliveries and, if complications arise, arrange for immediate transfer to hospitals; however, due to the typical long distances for such transport, 98% of deliveries in Sri Lanka today occur in institutions.[lvi]

Yemen should replicate the Sri Lankan health infrastructure model by strengthening its existing primary health services and then supplementing that structure with strategic investments in midwifery and maternal health. As it stands, just 25% of rural areas in Yemen are covered by health services. There exists no referral network or emergency transport system, and rugged roads compound this problem.[lvii] Human resources for health are inefficiently used: most health centers “only hire one general practice doctor who assumes the role of doctor, midwife and pharmacist.”[lviii] In larger institutions, because doctors do not rotate shifts, only a limited time frame is dedicated to emergency care.[lix]

Yemen should expand its health infrastructure, particularly in rural areas, by building up additional basic health facilities staffed by nurses and medical officers, who are supported by a strong referral network of doctors to provide higher-level care.[lx] Next, Yemen should invest in public health midwives, aiming to train an additional 5,000 midwives to reach a ratio of 1 midwife per 5,000 women.[lxi] (Though to do so, the Yemeni government must first incorporate midwives into the formal health care sector, and regulate midwifery practice.) The government has taken steps towards increasing its midwifery workforce, but only in areas without a health center.[lxii] This is the wrong approach: instead, the two should go hand-in-hand as in Sri Lanka. Ideally, the role of the midwife should be to provide antepartum and postpartum care at the patient’s home and to assist with delivery at a clinic or hospital. Institutional deliveries ensure access to higher-level care if birth complications arise, which is not available in most rural areas due to Yemen’s lack of a functioning emergency transport system. Today, 80% of deliveries in Yemen take place at home.[lxiii]

Yemen can expect that making the same strategic investments as Sri Lanka in basic health infrastructure and a public health midwifery program while instituting policy reform to empower women to make health-related decisions will generate a comparable outcome. The amazing scale of Sri Lankan progress in improving women’s health status, where maternal deaths have halved every 12 years from 1935 to today, is achievable and affordable for Yemen too.[lxiv] For, Sri Lanka’s great improvements in women’s health occurred at a relatively low cost: the nation spends just 3.5% of its GDP on health![lxv] Yemen should look to the Sri Lankan experience to address its gender-based disparities, and, in doing so, will see significant benefits to the health of women, children and its society at large.